NEW YORK STATE MEDICAID PROGRAM PHYSICIAN PROCEDURE CODES SECTION 5 - SURGERY

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NEW YORK STATE

MEDICAID PROGRAM

PHYSICIAN – PROCEDURE CODES

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SURGERY SECTION

GENERAL INFORMATION AND RULES

1. FEES: The fees are listed in the Physician Surgery Fee Schedule, available at

http://www.emedny.org/ProviderManuals/Physician/index.html

Listed fees are the maximum reimbursable Medicaid fees. Fees for the MOMS

Program can be found in the Enhanced Program fee schedule. Fees for office, home and hospital visits, consultations and other medical services are listed in the Fee Schedule entitled MEDICINE.

2. FOLLOW-UP (F/U) DAYS:

Listed dollar values for all surgical procedures include the surgery and the follow-up care for the period indicated in days in the column headed "F/U Days". Necessary follow-up care beyond this listed period is to be added on a fee-for-service basis. (See modifier -24)

3. BY REPORT:

When the value of a procedure is indicated as "By Report" (BR), an Operative Report must be submitted with the MMIS claim form for a payment determination to be made. The Operative Report must include the following information:

a. Diagnosis (post-operative)

b. Size, location and number of lesion(s) or procedure(s) where appropriate c. Major surgical procedure and supplementary procedure(s)

d. Whenever possible, list the nearest similar procedure by number according to these studies

e. Estimated follow-up period f. Operative time

Failure to submit an Operative Report when billing for a "By Report" procedure will cause your claim to be denied by MMIS.

4. ADDITIONAL SERVICES:

Complications or other circumstances requiring additional and unusual services concurrent with the procedure(s) or during the listed period of normal follow-up care, may warrant additional charges on a feeforservice basis. (See modifiers 24, 25, -79). When an additional surgical procedure(s) is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods will continue

concurrently to their normal terminations. (See modifiers -78, -79)

5. SEPARATE PROCEDURE:

Certain of the listed procedures are commonly carried out as an integral part of a total service and as such do not warrant a separate charge. When such a procedure is carried out as a separate entity, not immediately related to other services, the indicated value for "Separate Procedure" is applicable.

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6. MULTIPLE SURGICAL PROCEDURES:

a. When multiple or bilateral surgical procedures, which add significant time or complexity to patient care, are performed at the same operative session, the total dollar value shall be the value of the major procedure plus 50% of the value of the lesser procedure(s) unless otherwise specified. (For reporting bilateral surgical procedures, see modifier -50).

b. When an incidental procedure (eg, incidental appendectomy, lysis of adhesions, excision of previous scar, puncture of ovarian cyst) is performed through the same incision, the fee will be that of the major procedure only.

7. PROCEDURES NOT SPECIFICALLY LISTED:

Will be given values comparable to those of the listed procedures of closest

similarity. When no similar procedure can be identified, the MMIS procedure codes to be utilized may be found at the end of each section.

8. SUPPLEMENTAL SKILLS:

When warranted by the necessity of supplemental skills, values for services rendered by two or more physicians will be allowed.

9. SKILLS OF TWO SURGEONS

a. When the skills of two surgeons are required in the management of a specific surgical procedure, by prior agreement, the total dollar value may be apportioned in relation to the responsibility and work done, provided the patient is made aware of the fee distribution according to medical ethics. The value may be increased by 25 percent under these circumstances. See MMIS modifier -62. b. PHYSICIAN ASSISTANT/NURSE PRACTITIONER SERVICES FOR ASSIST

AT SURGERY: When a physician requests a nurse practitioner or a physician's

assistant to participate in the management of a specific surgical procedure in lieu of another physician, or requests a licensed midwife to participate in the

management of a Cesarean section, by prior agreement, the total value may

be apportioned in relation to the responsibility and work done, provided the patient is made aware of the fee distribution according to medical ethics. The value may be increased by 20 percent under these circumstances. The claim for these services will be submitted by the physician using the appropriate modifier.

10. MATERIALS SUPPLIED BY A PHYSICIAN:

Supplies and materials provided by the physician, eg, sterile trays/drugs, over and

above those usually included with the office visit or other services rendered may be

listed separately. List drugs, trays, supplies and materials provided. Identify as

99070.

Reimbursement for drugs (including vaccines and immunoglobulin) furnished by practitioners to their patients is based on the acquisition cost to the practitioner of the drug dose administered to the patient. For all drugs furnished in this fashion it is

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expected that the practitioner will maintain auditable records of the actual itemized invoice cost of the drug, including the numbers of doses of the drug represented on the invoice. New York State Medicaid does not intend to pay more than the

acquisition cost of the drug dosage, as established by invoice, to the practitioner. Regardless of whether an invoice must be submitted to Medicaid for payment, the practitioner is expected to limit his or her Medicaid claim amount to the actual invoice cost of the drug dosage administered.

11. PRIOR APPROVAL:

Payment for those listed procedures where the MMIS code number is underlined is dependent upon obtaining the approval of the Department of Health prior to

performance of the procedure. If such prior approval is not obtained, no reimbursement will be made.

12. DVS AUTHORIZATION (#):

Codes followed by # require an authorization via the dispensing validation system (DVS) before services are rendered.

13. INFORMED CONSENT FOR STERILIZATION:

When procedures are performed for the primary purpose of rendering an individual incapable of reproducing, and in all cases when procedures identified by MMIS codes 55250, 55450, 58565, 58600, 58605, 58611, 58615, 58670 and 58671 are performed, the following rules will apply:

a. The patient must be 21 years of age or older at the time to consent to sterilization.

b. The patient must have been informed of the risks and benefits of sterilization and have signed the mandated consent form, (DSS-3134) not less than 30 days nor more than 180 days prior to the performance of the procedure. In cases of premature delivery and emergency abdominal surgery, consent must have been given at least 72 hours prior to sterilization.

c. No bill will be processed for payment without a properly completed consent form. (Refer to Billing Section for completion instructions).

NOTE: For procedures performed within the jurisdiction of NYC the guidelines

established under NYC Local Law #37 of 1977 continue to be in force. 14. RECEIPT OF HYSTERECTOMY INFORMATION:

Hysterectomies must not be performed for the purpose of sterilization. When

hysterectomy procedures are performed and in all cases when procedures identified by MMIS codes 51925, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58953, 58954, 58956, 59135, or 59525 are billed, a properly completed "Hysterectomy Receipt of Information Form" must be attached to the bill

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for payment. No bill will be processed without a properly completed "Hysterectomy Receipt of Information Form", (DSS-3113).

15. BILLING GUIDELINES:

For additional general billing guidelines see the current CTP manual.

16. MMIS SURGERY MODIFIERS:

Note: NCCI associated modifiers are recognized for NCCI code pairs/related edits. For additional information please refer to the CMS website:

http://www.cms.hhs.gov/NationalCorrectCodInitEd/

-50 Bilateral Procedure (Surgical): Unless otherwise identified in the listings, bilateral surgical procedures requiring a separate incision that are performed at the same operative session, should be identified by the appropriate five digit code describing the first procedure. To indicate a bilateral surgical procedure was done add modifier -50 to the procedure number.

(Reimbursement will not exceed 150% of the maximum Fee Schedule amount. One claim line is to be billed representing the bilateral procedure. Amount billed should reflect total amount due.)

-54 Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier -54 to the usual procedure number. (Reimbursement will not exceed 80% of the maximum Fee Schedule amount.)

-62 Two Surgeons: When two surgeons (usually of different skills) work together as primary surgeons performing distinct part(s) of a single reportable

procedure, add the modifier –62 to the single definitive procedure code. [One surgeon should file one claim line representing the procedure performed by the two surgeons. Reimbursement will not exceed 125% of the maximum State Medical Fee Schedule amount.] If additional procedure(s) (including add-on procedure(s)) are performed during the same surgical session, separate code(s) may be reported without the modifier –62 added as

appropriate. NOTE: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier –80 added, as appropriate.

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-63 Procedure Performed on Infants Less Than 4 kg: Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician work commonly associated with these patients. This circumstance may be reported by adding modifier – 63 to the procedure number. Note: Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 69999 code

series. Modifier –63 should not be appended to any CPT codes listed in the Evaluation and Management Services, Anesthesia, Radiology,

Pathology/Laboratory, or Medicine sections. (Reimbursement will not exceed 100% of the maximum Fee Schedule amount.)

-66 Surgical Team: Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the "surgical team" concept. Such circumstances may be identified by each participating physician with the addition of the modifier -66 to the basic procedure number used for reporting services. (Reimbursement will not exceed 20% of the maximum Fee

Schedule amount.)

-78 Return to the Operating Room for a Related Procedure During the Postoperative Period: The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier -78 to the related procedure. (Reimbursement will not exceed 100% of the maximum Fee Schedule amount.)

-79 Unrelated Procedure or Service by the Same Practitioner During the Postoperative Period: The practitioner may need to indicate that the

performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by adding the modifier -79. (Reimbursement will not exceed 100% of the maximum Fee Schedule amount.)

-80 Assistant Surgeon: Surgical assistant services may be identified by adding the modifier -80 to the usual procedure number(s). (Reimbursement will not exceed 20% of the maximum Fee Schedule amount.)

-82 Assistant Surgeon: (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier -82 appended to the usual procedure code number(s).

(Reimbursement will not exceed 20% of the maximum Fee Schedule amount.)

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-AQ Physician Providing a Service in an Unlisted Health Professional Shortage Area (HPSA)

-AS Physician Assistant or Nurse Practitioner Services for Assist at Surgery: When the physician requests that a Physician Assistant or Nurse Practitioner assist at surgery, or requests a licensed midwife to assist for a Cesarean

section, in lieu of another physician, Modifier -AS should be added to the

appropriate code describing the procedure. One claim is to be filed. (Reimbursement will not exceed 120% of the maximum Fee Schedule amount).

-LT Left Side (used to identify procedures performed on the left side of the body): Add modifier –LT to the usual procedure code number. (Reimbursement will not exceed 100% of the Maximum Fee Schedule amount. One claim line should be billed.) (Use modifier –50 when both sides done at same

operative session.)

-RT Right Side (used to identify procedures performed on the right side of the body): Add modifier –RT to the usual procedure code number.

(Reimbursement will not exceed 100% of the Maximum Fee Schedule amount. One claim line should be billed.) (Use modifier –50 when both

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SURGERY SERVICES

GENERAL

10021 Fine needle aspiration; without imaging guidance 10022 with imaging guidance

INTERGUMENTARY SYSTEM

SKIN, SUBCUTANEOUS AND ACCESSORY STRUCTURES INCISION AND DRAINAGE

10030 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous

10040 Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)

10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single

10061 complicated or multiple

10080 Incision and drainage of pilonidal cyst; simple 10081 complicated

10120 Incision and removal of foreign body, subcutaneous tissues; simple 10121 complicated

10140 Incision and drainage of hematoma, seroma or fluid collection 10160 Puncture aspiration of abscess, hematoma, bulla or cyst 10180 Incision and drainage, complex, postoperative wound infection

EXCISION – DEBRIDEMENT

11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface

11001 each additional 10% of the body surface, or part thereof (List separately in addition to primary procedure)

(Use 11001 in conjunction with 11000)

11004 Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum

11005 abdominal wall, with or without fascial closure

11006 external genitalia, perineum and abdominal wall, with or without fascial closure

11008 Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to primary procedure)

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(Use 11008 in conjunction with 10180, 11004-11006)

(Do not report 11008 in conjunction with 11000-11001, 11010-11044)

(Report skin grafts or flaps separately when performed for closure at the same session as 11004-11008)

11010 Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues

11011 skin, subcutaneous tissue, muscle fascia, and muscle 11012 skin, subcutaneous tissue, muscle fascia, muscle, and bone 11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if

performed); first 20 sq cm or less

11043 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle, and/or fascia, if performed); first 20 sq cm or less

11045 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof

(List separately in addition to primary procedure) (Use 11045 in conjunction with 11042)

11046 Debridement, muscle and/or fascia (includes epidermis, dermis, and

subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to primary procedure

11047 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle, and/or fascia, if performed); each additional 20 sq cm, or part thereof

PARING OR CUTTING

11055 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion

11056 two to four lesions 11057 more than four lesions

BIOPSY

During certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. The obtaining of tissue for pathology during the course of these

procedures is a routine component of such procedures. This obtaining of tissue is not considered a separate biopsy procedure and is not separately reported. The use of a biopsy procedure code (eg, 11100, 11101) indicates that the procedure to obtain tissue

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for pathologic examination was performed independently, or was unrelated or distinct from other procedures/services provided at that time. Such biopsies are not considered components of other procedures when performed on different lesions or different sites on the same date, and are to be reported separately.

11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

11101 each separate/additional lesion

REMOVAL OF SKIN TAGS

Removal by scissoring, or any sharp method, ligature strangulation electrosurgical destruction or combination of treatment modalities including chemical or

electrocauterization of wound, with or without local anesthesia.

11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

11201 each additional ten lesions, or part thereof

SHAVING OF EPIDERMAL OR DERMAL LESIONS

Shaving is the sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full thickness dermal excision. This includes local anesthesia, chemical or electrocauterization of the wound. The wound does not require suture closure.

11300 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm. or less

11301 lesion diameter 0.6 to 1.0 cm 11302 lesion diameter 1.1 to 2.0 cm 11303 lesion diameter over 2.0 cm

11305 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less

11306 lesion diameter 0.6 to 1.0 cm 11307 lesion diameter 1.1 to 2.0 cm 11308 lesion diameter over 2.0 cm

11310 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less

11311 lesion diameter 0.6 to 1.0 cm 11312 lesion diameter 1.1 to 2.0 cm

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11313 lesion diameter over 2.0 cm

EXCISION – BENIGN LESIONS

Excision (including simple closure) of benign lesions of skin (eg, neoplasm, cicatricial, fibrous, inflammatory, congenital, cystic lesions), includes local anesthesia. See appropriate size and area below. For shave removal, see 11300 et seq., and for electrosurgical and other methods, see 17000 et seq.

Excision is defined as full thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed. Report separately each benign lesion excised. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision.

The excised diameter is the same whether the surgical defect is repaired in a linear fashion, or reconstructed (eg, with a skin graft).

The closure of defects created by incision, excision, or trauma may require intermediate or complex closure. Repair by intermediate or complex closure should be reported separately.

11400 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less

11401 excised diameter 0.6 to 1.0 cm 11402 excised diameter 1.1 to 2.0 cm 11403 excised diameter 2.1 to 3.0 cm 11404 excised diameter 3.1 to 4.0 cm 11406 excised diameter over 4.0 cm

11420 Excision, benign lesion including margins, except skin tag (unless listed

elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less 11421 excised diameter 0.6 to 1.0 cm

11422 excised diameter 1.1 to 2.0 cm 11423 excised diameter 2.1 to 3.0 cm 11424 excised diameter 3.1 to 4.0 cm 11426 excised diameter over 4.0 cm

11440 Excision, other benign lesion including margins, (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less 11441 excised diameter 0.6 to 1.0 cm

11442 excised diameter 1.1 to 2.0 cm 11443 excised diameter 2.1 to 3.0 cm 11444 excised diameter 3.1 to 4.0 cm

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11446 excised diameter over 4.0 cm

11450 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair

11451 with complex repair

11462 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair

11470 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal or umbilical; with simple or intermediate repair

(For bilateral procedure, add modifier 50)

EXCISION - MALIGNANT LESIONS

Excision (including simple closure) of malignant lesions of skin (eg, basal cell carcinoma, squamous cell carcinoma, melanoma) includes local anesthesia. (See appropriate size and body area below). For destruction of malignant lesions of skin, see destruction codes 17260-17286.

Excision is defined as full-thickness (through the dermis) removal of a lesion including margins, and includes simple (non-layered) closure when performed. Report separately each malignant lesion excised. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision. The excised diameter is the same whether the surgical defect is repaired in a linear fashion, or reconstructed (eg, with a skin graft).

The closure of defects created by incision, excision, or trauma may require intermediate or complex closure. Repair by intermediate or complex closure should be reported separately. For excision of malignant lesions requiring more than simple closure, i.e., requiring intermediate or complex closure, report 11600-11646 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes. For

reconstructive closure, see, 15002-15261, 15570-15770. See definition of intermediate or complex closure.

When frozen section pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal. Use only one code to report the additional excision and re-excision(s) based on the final widest excised

diameter required for complete tumor removal at the same operative session. To report a re-excision procedure performed to widen margins at a subsequent operative session, see codes 11600-11646, as appropriate.

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11600 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 0.5 cm or less 11601 excised diameter 0.6 to 1.0 cm 11602 excised diameter 1.1 to 2.0 cm 11603 excised diameter 2.1 to 3.0 cm 11604 excised diameter 3.1 to 4.0 cm 11606 excised diameter over 4.0 cm

11620 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less

11640 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less

NAILS

11720 Debridement of nail(s) by any method(s); one to five 11721 six or more

11730 Avulsion of nail plate, partial or complete, simple; single 11732 each additional nail plate

11740 Evacuation of subungual hematoma

11750 Excision of nail and nail matrix, partial or complete, (eg, ingrown or deformed nail) for permanent removal;

11752 with amputation of tuft of distal phalanx

11755 Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure)

11760 Repair of nail bed

11762 Reconstruction of nail bed with graft

11765 Wedge excision of skin of nail fold (eg, for ingrown toenail)

PILONIDAL CYST

11770 Excision of pilonidal cyst or sinus; simple 11771 extensive

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11772 complicated

INTRODUCTION

11900 Injection, intralesional; up to and including seven lesions 11901 more than seven lesions

(11900, 11901 are not to be used for preoperative local anesthetic injection) 11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct

color defects of skin, including micropigmentation; 6.0 sq cm or less 11921 6.1 to 20.0 sq cm

11922 each additional 20.0 sq cm, or part thereof (Report required) (List separately in addition to primary procedure)

11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less (Report

required)

11951 1.1 to 5 cc (Report required) 11952 5.1 to 10 cc (Report required) 11954 over 10 cc (Report required)

11960 Insertion of tissue expander(s) for other than breast, including subsequent expansion

11970 Replacement of tissue expander with permanent prosthesis 11971 Removal of tissue expander(s) without insertion of prosthesis 11976 Removal, implantable contraceptive capsules

11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)

11981 Insertion, non-biodegradable drug delivery implant 11982 Removal, non-biodegradable drug delivery implant

11983 Removal with reinsertion, non-biodegradable drug delivery implant

REPAIR (CLOSURE)

Use the codes in this section to designate wound closure utilizing sutures, staples, or tissue adhesives (eg, 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips. Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code.

DEFINITIONS:

The repair of wounds may be classified as Simple, Intermediate or Complex.

SIMPLE REPAIR: is used when the wound is superficial; ie, involving primarily epidermis

or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure. This includes local anesthesia and chemical or electrocauterization of wounds not closed. (For closure with adhesive strips, list appropriate Evaluation and Management service only).

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INTERMEDIATE REPAIR: includes the repair of wounds that, in addition to the above, require layer closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair.

COMPLEX REPAIR: includes the repairs of wounds requiring more than layered closure,

viz., scar revision, debridement, (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a defect for repairs (eg, excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions.

Instructions for listing services at time of wound repair:

1. The repaired wound(s) should be measured and recorded in centimeters, whether curved, angular or stellate.

2. When multiple wounds are repaired, add together the lengths of those in the same classification (see above) and from all anatomic sites that are grouped together into the same code descriptor. For example, add together the lengths of intermediate repairs to the trunk and extremities. Do not add lengths of repairs from different groupings of anatomic sites (eg, face and extremities). Also, do not add together lengths of different classifications (eg, intermediate and complex repairs).

3. Decontamination and/or debridement: Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure. (For extensive debridement of soft tissue and/or bone, see 11044)

(For extensive debridement of soft tissue and/or bone, not associated with open fracture(s) and/or dislocation(s) resulting from penetrating and/or blunt trauma, see 11044.)

(For extensive debridement of subcutaneous tissue, muscle fascia, muscle, and/or bone associated with open fracture(s) and/or dislocation(s), see 11010-11012.) 4. Involvement of nerves, blood vessels and tendons: Report under appropriate system

(Nervous, Cardiovascular, Musculoskeletal) for repair of these structures. The repair of these associated wounds is included in the primary procedure.

Simple ligation of vessels in an open wound is considered as part of any wound closure.

Simple exploration of nerves, blood vessels or tendons exposed in an open wound is also considered part of the essential treatment of the wound and is not a separate procedure unless appreciable dissection is required. If the wound requires

enlargement, extension of dissection (to determine penetration), debridement, removal of foreign body(s), ligation or coagulation of minor subcutaneous and/or muscular blood vessel(s), of the subcutaneous tissue, muscle, fascia, and/or

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muscle, not requiring thoracotomy or laparotomy, use codes 20100-20103, as appropriate.

REPAIR-SIMPLE

12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less

12002 2.6 cm to 7.5 cm 12004 7.6 cm to.12.5 cm 12005 12.6 cm to 20.0 cm 12006 20.1 cm to 30.0 cm 12007 over 30.0 cm

12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less

12013 2.6 cm to 5.0 cm 12014 5.1 cm to 7.5 cm 12015 7.6 cm to 12.5 cm 12016 12.6 cm to 20.0 cm 12017 20.1 cm to 30.0 cm 12018 over 30.0 cm

12020 Treatment of superficial wound dehiscence; simple closure

REPAIR-INTERMEDIATE

12031 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less

12032 2.6 cm to 7.5 cm 12034 7.6 cm to.12.5 cm 12035 12.6 cm to 20.0 cm 12036 20.1 cm to 30.0 cm 12037 over 30.0 cm

12041 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less 12042 2.6 cm to 7.5 cm 12044 7.6 cm to.12.5 cm 12045 12.6 cm to 20.0 cm 12046 20.1 cm to 30.0 cm 12047 over 30.0 cm

12051 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less

12052 2.6 cm to 5.0 cm 12053 5.1 cm to 7.5 cm 12054 7.6 cm to 12.5 cm 12055 12.6 cm to 20.0 cm

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12056 20.1 cm to 30.0 cm 12057 over 30.0 cm

REPAIR-COMPLEX

13100 Repair, complex, trunk; 1.1 cm to 2.5 cm 13101 2.6 cm to 7.5 cm

13102 each additional 5 cm or less

13120 Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm 13121 2.6 cm to 7.5 cm

13131 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm

13132 2.6 cm to 7.5cm

13151 Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm 13152 2.6 cm to 7.5 cm

13160 Secondary closure of surgical wound or dehiscence, extensive or complicated

ADJACENT TISSUE TRANSFER OR REARRANGEMENT

Excision (including lesion) and/or repair by adjacent tissue transfer or rearrangement (eg, Z-plasty, W-plasty, V-Y plasty, rotation flap, advancement flap, double pedicle flap). When applied in repairing lacerations, the procedures listed must be developed by the surgeon to accomplish the repair. They do not apply when direct closure or

rearrangement of traumatic wounds incidentally result in these configurations.

Skin graft necessary to close secondary defect is considered an additional procedure. For purposes of code selection, the term “defect’’ includes the primary and secondary defects. The primary defect resulting from the excision and the secondary defect resulting from flap design to perform the reconstruction are measured together to determine the code.

14000 Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less 14001 defect 10.1 sq cm to 30.0 sq cm

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14020 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm. or less

14021 defect 10.1 sq cm to 30.0 sq cm

14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less

14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less

14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm

14302 each additional 30.0 sq cm, or part thereof (List separately in addition to code)

14350 Filleted finger or toe flap, including preparation of recipient site

SKIN REPLACEMENT SURGERY

Identify by size and location of the defect (recipient area) and the type of graft or skin substitute; includes simple debridement of granulation tissue or recent avulsion. When a primary procedure such as orbitectomy, radical mastectomy or deep tumor removal requires skin graft for definitive closure, see appropriate anatomical subsection for primary procedure and this section for skin graft or skin substitute.

Repair of donor site requiring skin graft or local flaps is to be added as an additional procedure.

Codes 15002 and 15005 describe burn and wound preparation or incisional or

excisional release of scar contracture resulting in an open wound requiring a skin graft. Code 15100 describe the application of skin replacements and skin substitutes. The following definition should be applied to those codes that reference “100 sq cm or one percent of body area of infants and children” when determining the involvement of body size: The measurement of 100 sq cm is applicable to adults and children age 10 and over, percentages of body surface area apply to infants and children under the age of 10.

These codes are not intended to be reported for simple graft application alone or

application stabilized with dressings (eg, simple gauze wrap) without surgical fixation of the skin substitute/graft. The skin substitute/graft is anchored using the surgeon’s choice of fixation. When services are performed in the office, the supply of the skin substitute/graft should be reported separately. Routine dressing supplies are not reported separately.

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15002 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children

15003 each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children

15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children

15005 each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children

(Report 15002-15005 in conjunction with code for appropriate skin grafts or replacements [15050-15261,]. List the graft or replacement separately by its procedure number when the graft, immediate or delayed, is applied)

AUTOGRAFT/TISSUE CULTURED AUTOGRAFT

15040 Harvest of skin for tissue cultured skin autograft, 100 sq cm or less

15050 Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), up to defect size 2 cm diameter

15100 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children (except 15050)

15101 each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof

15110 Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children

15115 Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children

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15120 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children (except 15050)

15130 Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children

15135 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or one percent of body area of infants and children

15150 Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less 15151 additional 1 sq cm to 75 sq cm

(List separately in addition to primary procedure) (Do not report 15151 more than once per session) (Use 15151 in conjunction with 15150)

15152 each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof

15155 Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less

15156 additional 1 sq cm to 75 sq cm

(List separately in addition to primary procedure) (Do not report 15156 more than once per session) (Use 15156 in conjunction with 15155)

15157 each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof

15200 Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less

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15220 Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less

15221 each additional 20 sq cm, or part thereof

15240 Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less

15260 Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less

SKIN SUBSTITUTE GRAFTS

15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

15272 each additional 25 sq cm wound surface area, or part thereof (List separately in addition to primary procedure)

(Do not report 15271, 15272 in conjunction with 15273, 15274)

15273 Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

15274 each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to primary procedure)

15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

15276 each additional 25 sq cm wound surface area, or part thereof (List separately in addition to primary procedure)

(Do not report 15275, 15276 in conjunction with 15277, 15278)

15277 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area

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greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

15278 each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to primary procedure)

FLAPS (SKIN AND/OR DEEP TISSUES)

Regions listed refer to recipient area (not donor site) when flap is being attached in transfer or to final site.

Regions listed refer to donor site when tube is formed for later transfer or when delay of flap is prior to transfer.

Procedures 15570-15738 do not include extensive immobilization, (eg, large plaster casts and other immobilizing devices are considered additional separate procedures) Repair of donor site requiring skin graft or local flaps is considered an additional separate procedure.

15570 Formation of direct or tubed pedicle, with or without transfer; trunk 15572 scalp, arms, or legs

15574 forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet 15576 eyelids, nose, ears, lips, or intraoral

15600 Delay of flap or sectioning of flap (division and inset); at trunk 15610 at scalp, arms, or legs

15620 at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet 15630 at eyelids, nose, ears, or lips

15650 Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location

15731 Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)

15732 Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, masseter muscle, sternocleidomastoid, levator scapulae) 15734 trunk

15736 upper extremity 15738 lower extremity

Codes 15732-15738 are described by donor site of the muscle, myocutaneous, or fasciocutaneous flap.

OTHER FLAPS AND GRAFTS

Repair of donor site requiring skin graft or local flaps should be reported as an additional procedure.

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15740 Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel

15750 neurovascular pedicle

15756 Free muscle or myocutaneous flap with microvascular anastomosis 15757 Free skin flap with microvascular anastomosis

15758 Free fascial flap with microvascular anastomosis

15760 Graft; composite (full thickness of external ear or nasal ala), including primary closure, donor area

15770 derma-fat-fascia

15775 Punch graft for hair transplant; 1 to 15 punch grafts (Report required) 15776 more than 15 punch grafts (Report required)

15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk)

(List separately in addition to primary procedure)

(For bilateral breast procedure, report 15777 with modifier 50)

OTHER PROCEDURES

15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)

15781 segmental, face

15782 regional, other than face

15783 superficial, any site, (eg, tattoo removal) (Report required) 15786 Abrasion; single lesion (eg, keratosis, scar)

15787 each additional four lesions or less

15788 Chemical peel, facial; epidermal 15789 dermal

15792 Chemical peel, nonfacial; epidermal 15793 dermal

15819 Cervicoplasty

15820 Blepharoplasty, lower eyelid;

15821 with extensive herniated fat pad 15822 Blepharoplasty, upper eyelid;

15823 with excessive skin weighting down lid (For bilateral blepharoplasty, add modifier 50) 15824 Rhytidectomy; forehead

(For bilateral rhytidectomy, add modifier 50)

15825 neck with platysmal tightening (platysmal flap, P-flap) 15826 glabellar frown lines

15828 cheek, chin, and neck

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15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

(Do not report 15830 in conjunction with 12031, 12032, 12034, 12035, 12036, 12037, 13100, 13101, 13102, 14000-14001, 14302) 15832 thigh 15833 leg 15834 hip 15835 buttock 15836 arm 15837 forearm or hand 15838 submental fat pad 15839 other area

(For bilateral procedure, add modifier 50)

15840 Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) (For bilateral procedure, add modifier 50)

15841 free muscle graft (including obtaining graft) 15842 free muscle flap by microsurgical technique 15845 regional muscle transfer

15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (Report required)

15851 Removal of sutures under anesthesia (other than local), other surgeon 15852 Dressing change (for other than burns) under anesthesia (other than local)

(See Rule 4)

15860 Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft

15876 Suction assisted lipectomy; head and neck (Report required) 15877 trunk (Report required)

15878 upper extremity (Report required) 15879 lower extremity (Report required)

PRESSURE ULCERS (DECUBITIS ULCERS)

15920 Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture 15922 with flap closure

15931 Excision, sacral pressure ulcer, with primary suture; 15933 with ostectomy

15934 Excision, sacral pressure ulcer, with skin flap closure 15935 with ostectomy

15936 Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;

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15937 with ostectomy

15940 Excision, ischial pressure ulcer, with primary suture; 15941 with ostectomy

15944 Excision, ischial pressure ulcer, with skin flap closure; 15945 with ostectomy

15946 Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure

15950 Excision, trochanteric pressure ulcer, with primary suture; 15951 with ostectomy

15952 Excision, trochanteric pressure ulcer, with skin flap closure; 15953 with ostectomy

15956 Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;

15958 with ostectomy

15999 Unlisted procedure, excision pressure ulcer

BURNS, LOCAL TREATMENT

Procedures 16000-16036 refer to local treatment of burned surface only. Codes 16020-16030 include the application of materials (eg, dressings) not described in 15100. List percentage of body surface involved and depth of burn.

16000 Initial treatment, first degree burn, when no more than local treatment is required

16020 Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)

16025 medium (eg, whole face or whole extremity or 5% to 10% total body surface area)

16030 large (eg, more than one extremity, or greater than 10% total body surface area)

16035 Escharotomy; initial incision 16036 each additional incision

(List separately in addition to primary procedure) (Use 16036 in conjunction with code 16035)

DESTRUCTION

Destruction means the ablation of benign, pre-malignant or malignant tissues by any method, with or without curettement, including local anesthesia, and not usually requiring closure.

Any method includes electrosurgery, cryosurgery, laser and chemical treatment. Lesions include condylomata, papillomata, molluscum contagiosum, herpetic lesions,

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warts (ie, common, plantar, flat), milia, or other benign, pre-malignant (eg, actinic keratoses), or malignant lesions.

DESTRUCTION, BENIGN OR PREMALIGNANT LESIONS

17000 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion

(Report required)

17003 second through 14 lesions, each (Report required) (List separately in addition to code for first lesion) (Use 17003 in conjunction with 17000)

17004 15 or more lesions (Report required)

(Do not report 17004 in addition to 17000 – 17003)

17106 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm

17107 10.0 - 50.0 sq cm 17108 over 50.0 sq cm

17110 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions

17111 15 or more lesions

17250 Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) (17250 is not to be used with excision/removal codes for the same lesions)

DESTRUCTION, MALIGNANT LESIONS, ANY METHOD

17260 Destruction, malignant lesion, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less

17261 lesion diameter 0.6 to 1.0 cm 17262 lesion diameter 1.1 to 2.0 cm 17263 lesion diameter 2.1 to 3.0 cm

17264 lesion diameter 3.1 to 4.0 cm (Report required) 17266 lesion diameter over 4.0 cm (Report required)

17270 Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less

17271 lesion diameter 0.6 to 1.0 cm 17272 lesion diameter 1.1 to 2.0 cm 17273 lesion diameter 2.1 to 3.0 cm 17274 lesion diameter 3.1 to 4.0 cm 17276 lesion diameter over 4.0 cm

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17280 Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less

17281 lesion diameter 0.6 to 1.0 cm 17282 lesion diameter 1.1 to 2.0 cm

17283 lesion diameter 2.1 to 3.0 cm (Report required) 17284 lesion diameter 3.1 to 4.0 cm (Report required) 17286 lesion diameter over 4.0 cm (Report required)

MOHS’ MICROGRAPHIC SURGERY

Mohs micrographic surgery is a technique for the removal of complex or ill-defined skin cancer with histologic examination of 100% of the surgical margins. It requires a single physician to act in two integrated but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports the services separately, these codes should not be reported. The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces, and each piece is embedded into an individual tissue block for histopathologic examination. Thus a tissue block in Mohs surgery is defined as an individual tissue piece embedded in a mounting medium for sectioning.

If repair is performed, use separate repair, flap, or graft codes. If a biopsy of a

suspected skin cancer is performed on the same day as Mohs surgery because there was no prior pathology confirmation of a diagnosis, then report diagnostic skin biopsy (11100, 11101).

17311 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks

17312 each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to primary procedure)

17313 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks

17314 each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to primary procedure)

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17315 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (Report required) (List separately in addition to primary procedure)

17340 Cryotherapy (C02 slush, liquid N2) for acne

17360 Chemical exfoliation for acne (eg, acne paste, acid) 17380 Electrolysis epilation, each 30 minutes

17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue

BREAST INCISION

19000 Puncture aspiration of cyst breast; 19001 each additional cyst

19020 Mastotomy with exploration or drainage of abscess, deep

19030 Injection procedure only for mammary ductogram or galactogram

EXCISION

(To report bilateral procedures, use modifier -50)

Excisional breast surgery includes certain biopsy procedures, the removal of cysts or other benign or malignant tumors or lesions, and the surgical treatment of breast and chest wall malignancies. Biopsy procedures may be percutaneous or open, and they involve the removal of differing amounts of tissue for diagnosis.

Breast biopsies are reported using codes 19100-19103. The open excision of breast lesions (eg, lesions of the breast ducts, cysts, benign or malignant tumors), without specific attention to adequate surgical margins, with or without the preoperative placement of radiological markers, is reported using codes 19110-19126. Partial mastectomy procedures (eg, lumpectomy, tylectomy, quadrantectomy, or

segmentectomy) describe open excisions of breast tissue with specific attention to adequate surgical margins.

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Partial mastectomy procedures are reported using codes 19301 or 19302 as

appropriate. Documentation for partial mastectomy procedures includes attention to the removal of adequate surgical margins surrounding the breast mass or lesion.

Total mastectomy procedures include simple mastectomy, complete mastectomy, subcutaneous mastectomy, modified radical mastectomy, radical mastectomy, and more extended procedures (eg, Urban type operation). Total mastectomy procedures are reported using codes 19303-19307 as appropriate.

Excisions or resections of chest wall tumors including ribs, with or without

reconstruction, with or without mediastinal lymphadenectomy, are reported using codes 19260, 19271, or 19272. Codes 19260-19272 are not restricted to breast tumors and are used to report resections of chest wall tumors originating from any chest wall component.

19081 Biopsy, breast, with placement of breast localization devices(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance

19082 each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure)

19083 Biopsy, breast with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance

19084 each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)

19085 Biopsy, breast with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance

19086 each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)

19100 Biopsy of breast; percutaneous, needle core, not using needle guidance (separate procedure)

19101 open, incisional

19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma

(Do not report 19105 in conjunction with 76940, 76942)

19110 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct

19112 Excision of lactiferous duct fistula

19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions

19125 Excision of breast lesion identified by pre-operative placement of radiological marker, open; single lesion

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19126 each additional lesion separately identified by a preoperative radiological maker

(List separately in addition to primary procedure) (Use 19126 in conjunction with code 19125) 19260 Excision of chest wall tumor including ribs

19271 Excision of chest wall tumor involving ribs, with plastic reconstruction; without mediastinal lymphadenectomy

19272 with mediastinal lymphadenectomy

(Do not report 19260, 19271, 19272 in conjunction with 32100, 32503, 32504, 32551, 32554, 32555)

INTRODUCTION

19281 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, first lesion, including mammographic

guidance

19282 each additional lesion, including mammographic guidance (List separately in addition to primary procedure)

19283 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, first lesion, including stereotactic guidance 19284 each additional lesion, including stereotactic guidance

19285 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, first lesion, including ultrasound guidance 19286 each additional lesion, including ultrasound guidance

19287 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, first lesion, including magnetic resonance guidance

19288 each additional lesion, including magnetic resonance guidance (List separately in addition to primary procedure)

19296 Placement of radiotherapy afterloading expandable catheter (single or

multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy (Report required)

19297 concurrent with partial mastectomy

(List separately in addition to primary procedure) (Use 19297 in conjunction with code 19301 or 19302)

19298 Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance

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MASTECTOMY PROCEDURES

19300 Mastectomy for gynecomastia

19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);

19302 with axillary lymphadenectomy 19303 Mastectomy, simple, complete 19304 Mastectomy, subcutaneous

19305 Mastectomy, radical, including pectoral muscles, axillary lymph nodes

19306 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation)

19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle

REPAIR AND/OR RECONSTRUCTION

(To report bilateral procedures, use modifier -50) 19316 Mastopexy (unilateral)

19318 Reduction mammaplasty (unilateral)

19324 Mammaplasty, augmentation; without prosthetic implant 19325 with prosthetic implant

19328 Removal of intact mammary implant 19330 Removal of implant material

19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

19350 Nipple/areola reconstruction 19355 Correction of inverted nipples

19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion

19361 Breast reconstruction with latissimus dorsi flap, without prosthetic implant 19364 Breast reconstruction with free flap

(19364 includes harvesting of the flap, microvascular transfer, closure of the donor site, and inset shaping the flap into a breast)

19366 Breast reconstruction with other technique

19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site;

19368 with microvascular anastomosis (supercharging)

19369 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site

19370 Open periprosthetic capsulotomy, breast 19371 Periprosthetic capsulectomy, breast

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19380 Revision of reconstructed breast

19396 Preparation of moulage for custom breast implant (Report required)

19499 Unlisted procedure, breast

MUSCULOSKELETAL SYSTEM

Casts and strapping procedures appear at the end of this section.

The services listed below include the application and removal of the first cast or traction device only. Subsequent replacement of cast and/or traction device may require an additional listing.

DEFINITIONS:

The terms "closed treatment”, "open treatment" and "percutaneous skeletal fixation" have been carefully chosen to accurately reflect current orthopedic procedural treatments.

CLOSED TREATMENT - specifically means that the fracture site is not surgically opened

(exposed to the external environment and directly visualized). This terminology is used to describe procedures that treat fractures by three methods: 1) without manipulation; 2) with manipulation; or 3) with or without traction.

OPEN TREATMENT - is used when the fractured bone is either: 1) surgically opened

(exposed to the external environment) and the fracture (bone ends) visualized and internal fixation may be used; or 2) the fractured bone is opened remote from the

fracture site in order to insert an intramedullary nail across the fracture site (the fracture site is not opened and visualized).

PERCUTANEOUS SKELETAL FIXATION - describes fracture treatment which is neither

open nor closed. In this procedure, the fracture fragments are not visualized, but fixation (eg, pins) is placed across the fracture site, usually under x-ray imaging.

The type of fracture (eg, open, compound, closed) does not have any coding correlation with the type of treatment (eg, closed, open or percutaneous) provided.

The codes for treatment of fractures and joint injuries (dislocations) are categorized by the type of manipulation (reduction) and stabilization (fixation or immobilization). These codes can apply to either open (compound) or closed fractures or joint injuries.

Skeletal traction is the application of a force (distracting or traction force) to a limb segment through a wire, pin, screw or clamp that is attached (eg, penetrates) to bone. Skin traction is the application of a force (longitudinal) to a limb using felt or strapping applied directly to skin only.